Provider Manual
Introduction and Commitment to Providers
Introduction to the Provider Manual
Our Provider Service Commitment
Contact Us!
page 3
page 4
page 5
Participating Provider Commitments
24 Hour Access to Medical Care
Appointment Standards to Access Providers of Care
In Office Wait Time
page 6
page 6
page 7
Member Eligibility and Benefits Information
Verification of Eligibility and Benefits
Sample of Fully Insured Group ID Card
Guide to the QCCH ID Card
page 8
page 8
page 9
Claim Guidelines
Advanced Beneficiary Notification
Anesthesia Reimbursement Guidelines
Assignment of Benefits
Assistant Surgery
Check issue resolution
Coordination of Benefits
Laboratory Handling Fees
Laboratory Professional Component
Lesser Of Policy
Modifiers
Multiple Procedure Discount
Prevailing Policy
Rate Calculations When Not on Schedule or Exhibits
Sales Tax
Timely Filing
page 10
page 10
page 11
page 12
page 12
page 12
page 13
page 13
page 13
page 14
page 15
page 15
page 16
page 16
page 16
Provider Claim Inquiry and Provider Appeals
Provider Claim Inquiry
Provider Claim Inquiry Form
Provider Appeal
Provider Appeal Form
page 17
page 18
page 19
page 20
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Credentialing and Recredentialing
General Policy
Professional Liability Malpractice Coverage
page 21
page 21
Medical Services
Case Management Program
Utilization Management Program
page 22
page 22
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Introduction and Commitment to Providers
Introduction to the Provider Manual
Welcome to Quad City Community Healthcare. We are pleased you have elected to become a
participating physician or provider in an effort to provide our Members with high quality, costeffective medical care.
This Provider Manual introduces you to Quad City Community Healthcare. We are confident
you will find this information useful and hope that you and your office staff will read it carefully.
From time to time, there may be changes in established policies and procedures. We will let
you know about these changes as quickly as possible to ensure proper administration. When
such changes occur, the updates will be available via the Provider Page on the Quad City
Community Healthcare website (www.QCCHealth.com). Please note, provisions in your
contract will supersede the information in this manual if there are items that conflict.
We are your LOCAL health plan and we understand that your support and involvement are
critical to our success. Therefore, we encourage you to share with us your thoughts on how
we can improve our products or services. Please feel free to call our Provider Services
Department anytime should you have questions or concerns, or wish to discuss your
participation in our network.
The Provider Services Department can be reached at the following:
Quad City Community Healthcare
246 W 3rd Street Suite 100
Davenport, IA 52801
Phone: (563) 322-8995 or (888) 498-7224
Fax: (563) 322-1071
Normal Business days, Monday - Friday 8:00 am to 5:00 pm
Again, we appreciate your participation in the Quad City Community Healthcare Provider
Network. We look forward to working with you to manage our health care programs and serve
the needs of our Members.
The material in this Provider Manual is copyrighted. Text, graphics, or any other materials, may not be copied, reproduced, modified,
published, distributed or displayed in any form, including electronic format, except it may be downloaded from QUAD CITY COMMUNITY
HEALTHCARE'S WEBSITE and printed for personal noncommercial use. Reprinting of any material in this document for any other purpose is
strictly prohibited unless Quad City Community Healthcare provides written permission.
Quad City Community Healthcare is happy to make this Provider Manual available to WEBSITE users. However, Quad City Community
Healthcare cannot warrant or control the quality, accuracy, or validity of the information posted on the WEBSITE. Use of such information is at
the risk of the accessing user and the accessing user assumes all liabilities that may result from such use.
The procedures contained in the Provider Manual should not be construed as a substitute for the exercise of the medical judgment of the
physician or provider.
6/1/08
Manual Last Updated 7/1/2014
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Our Provider Service Commitment
Quad City Community Healthcare Provider Service Representatives are located right here in
Quad City. They have the responsibility for ensuring that all of our providers have a positive
experience with our Plan when they call or visit our office. They are experienced and friendly,
and strive for prompt issue resolution. Our Provider Service Representatives are the liaison
between Quad City Community Healthcare and our providers and have the unique opportunity
to help our members by communicating in a knowledgeable and pleasant manner, while
respecting the needs of our providers. It is with this type of local quality service and prompt
issue resolution that sets Quad City Community Healthcare above other, larger national
competitors.
Quad City Community Healthcare’s Provider Service Representatives are dedicated to:
•
•
•
•
•
•
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Answering the phones pleasantly and promptly.
Treating the provider and office staff with respect, understanding and compassion.
Listening attentively and asking appropriate questions to accurately interpret the needs
of our providers and office staff.
Striving for prompt issue resolution with consistent and accurate responses to
demonstrate superior quality service.
Reviewing customer satisfaction statistics to enable them to perform their job duties in
an informed and efficient manner.
Documenting their actions to provide verification and consistency of responses.
Educating our providers and their staff on Quad City Community Healthcare benefits
and procedures.
As part of our effort to continuously improve, Quad City Community Healthcare monitors our
Provider Service statistics with the goal of exceeding the service expectations of our providers
and their office staff.
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Contact Us!
QUAD CITY
COMMUNITY HEALTHCARE
For Local Customer and Provider Service and Quick Issue Resolution
Dial
1-563-322-8995
Or
1-888-498-7224
Speak directly to a Local, Friendly,
Experienced
Service Representative
For Local Service and Issue Resolution
Our normal business hours are Monday thru Friday from 8:00 am to 5:00 pm central
standard time.
Holiday closures will be posted at www.qcchealth.com.
Secure voice mail messages for urgent needs are retrieved during weather or
emergency closures during regular business hours.
If there is a medical emergency, call 911 or go to the nearest Emergency Facility.
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Participating Provider Commitments
24 hour Access to Medical Care
Provisions for 24 hour access to medical care
Providers shall have the appropriate methods for directing patients to seek medical care when
they themselves are not available. The provider shall arrange for the provision of emergency
situations 24 hours a day, 7 days a week.
Providers shall provide information to the patients on how they may seek medical care when
the provider is not available for times such as normal business hours, lunch, vacation, or after
hours.
Providers shall arrange for coverage with another in plan provider during times when
unavailable. After hour answering services and or systems must be in place for patients to be
directed on how to reach the provider or another provider designated to treat the patient.
After hour telephone access to providers
Providers or designated provider providing coverage, shall return a patient’s telephone call
within one hour of receiving the call after regular office hours.
Appointment Standards to Access Providers of Care
Emergent Crisis Care is defined as the evaluation and management of a condition, injury or
illness with symptoms that require immediate attention or care when the patient is in jeopardy
of a life threatening or permanent injury/disability if appropriate medical care is not immediately
provided.
Emergent Crisis Care patients should be seen immediately or referred to an emergency care
facility as appropriate.
Urgent Care is defined as the evaluation and management of an unexpected condition, injury
or illness that is not life threatening or could cause permanent injury/disability that cannot be
reasonably postponed but is not considered emergent.
Urgent Care patients should be seen within a 24 hour period as appropriate.
Routine Care is defined as a) care for a non-symptomatic patient involves evaluation and
management of an established patient including patient history, physical examination,
preventative screening, immunizations and medical decision making b) care for a symptomatic
patient involves evaluation and management of a symptomatic new or established patient for
chronic disease management, problem focused history, physical examination and medical
decision making.
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Routine Care patient non-symptomatic should be seen within 4 weeks as appropriate.
Routine Care patient that is symptomatic should be seen within 5 days as appropriate.
Initial Appointment is defined as a new patient not seen by the provider within the last 36
months as care for a new non-symptomatic patient involving the evaluation and management
of patient including patient history, physical examination, preventative screening,
immunizations and medical decision making.
Initial Appointment patients should be seen within 8 weeks as appropriate.
Providers participating with Quad City Community Healthcare agree to accept patients if their
practice is accepting patients that are participating with other health insurance payors/carriers
and hold the same office hours and policies without discrimination with other payors/carriers.
In Office Wait Time
If a patient is scheduled for an appointment and arrives on time, the wait time should be less
than 30 minutes.
Wait time should be measure from the scheduled appointment time until the provider sees the
patient.
If an unforeseen circumstance should arise that would make it impossible to see the patient
within the 30 minute wait time period, the office/clinic staff should offer the following options:
•
•
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7
Explain an unforeseen circumstance has arisen
Offer the patient to continue to wait
Reschedule the appointment
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Member Eligibility and Benefits Information
Verification of Eligibility and Benefits
Providers of service to QCCH members should review member ID cards for verification and
identification of the member. A member ID card does not guarantee eligibility or participation
in the QCCH health plans. Members may change plans, benefits may change, member may
term with the plan or there may be fraudulent use of the ID card.
For eligibility and benefit information please contact Customer Service. Verification of
eligibility and benefit information is not a guarantee for payment of a claim. Any claim
submitted to QCCH will be subject to eligibility and the terms, conditions, limitations and
exclusions of the policy at the time of service.
Sample of Fully Insured Group ID Card
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Guide to the QCCH ID Card
FRONT CARD
ELEMENT
EXPLANATION
Quad City Community
Healthcare Logo
MEMBER
Group Name
Group #
Member
Member ID
DEPENDENTS
Dependents
Coverage
The member’s health plan. The top of the card also provides the address
and telephone number for you to contact Quad City Community Healthcare
MEDICAL PPO PLAN
Madison National Life
Insurance Company Logo
In-Network Co pays
PHARMACY PLAN
NPS Logo
RxBin, Rx PCN, Rx Group
Retail Co pays
Enrolled group’s name
Enrolled group’s identification number
Enrolled member’s name
Enrolled member’s identification number
Enrolled dependent(s) first and last name(s)
Displays the coverages for each dependent (M = medical; D = dental; Rx =
prescription drugs)
Quad City Community Healthcare is underwritten by Madison National Life
Insurance Company
Lists the co pays associated with the member’s medical plan for covered
services when received from a Participating Provider. See your medical
plan for more details.
Quad City Community Healthcare’s Pharmacy Benefit Manager (PBM) for
pharmacy services
NPS and Pharmacy purposes only
Lists the co pays associated with the member’s pharmacy plan for covered
services. See your pharmacy plan for more details.
BACK CARD
ELEMENT
EXPLANATION
MEDICAL CLAIMS
SUBMISSION
PREAUTHORIZATION
Address for claims submission. Also includes telephone numbers for
members to use in contacting Quad City Community Healthcare.
Reminder to members to show their ID card to their provider. Also includes
the telephone number when preauthorization is required in advance of
certain services.
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Claim Guidelines
The following guidelines are in response to most frequently asked questions. Not all
guidelines are listed in this provider manual. If you have questions regarding claims issues or
additional claim guidelines please call customer service at 1-888-498-7224 or 563-322-8995.
Providers, practitioners, facilities and ancillary providers must bill on the appropriate CMS
approved forms or formats. All providers must bill for services rendered under their unique NPI
number. A provider in attendance of the care of a member must bill for the services for that
member. Incident to another provider billing is not accepted by the health plan. For billing of
Locum Tenens, please contact provider service.
Advanced Beneficiary Notification
Services and Supplies that are not covered by a benefit under a member’s health plan require
Advanced Beneficiary Notification. Providers of Services and Supplies must provide a
member in advance of receiving the service or supplies with a clear and concise written form
or document that outlines the member’s financial responsibility of services and or supplies that
are not covered.
Included in the Advanced Beneficiary Notification of the non-covered service or supply there
must be a clear explanation as to why the service or supply is not covered. Reason(s) may be
as follows but not limited to the following: no benefit for a service or supply, benefit for a
service or supply has been exhausted within the limitations of the health plan, service or
supply is cosmetic or for convenience and are not a covered benefit under the health plan.
Both the member and provider must sign the form or document prior to the initiation of any
service or supply that is not covered under the beneficiary’s health plan in order for the
beneficiary to clearly be informed of their financial responsibility prior to the service or supply.
Failure to give Advanced Beneficiary Notification may forfeit a provider’s right to seek
reimbursement for charges not covered under the member’s health plan.
Anesthesia Reimbursement Guidelines
Quad City Community Healthcare reimburses for ASA Relative Values. Codes 00100-01999
are reimbursed at ASA base units plus time units when applicable as published in the current
years Relative Value Guide by The American Society of Anesthesiologists.
ASA base units plus time units should be billed on the appropriate CMS approved form. Time
units should be billed as a unit and not in minutes. A time unit equals 15 minutes. For
example 90 minutes equals 6 time units. You would bill the total of adding your ASA base
units and the time units together as the "total units". Reimbursement will be made based on
the contractual rate multiplied by the total units.
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Time is defined in the Relative Value Guide as follows:
"Anesthesia time begins when the anesthesiologist begins to prepare the patient for
anesthesia care in the operating room or in an equivalent area, and ends when the
anesthesiologist is no longer in personal attendance, that is, when the patient is safely placed
under post-anesthesia supervision."
No additional reimbursement is considered for physical status modifiers that indicate
complexity.
Add on codes for qualifying Circumstances would not be reported alone but may be reported
as additional procedure when such extraordinary conditions or circumstances apply. These
codes are listed in the current Relative Value Guide.
Split billing is not reimbursable. The provider in attendance for the majority of the care will bill
for the services provided regardless if a different provider begins the procedure and another
monitors or completes the procedure.
The following CPT’s billed by the specialty of anesthesia will reimburse at the ASA unit rate as
specified in the table below. Medical records should accompany the claim for reimbursement
to be considered.
99100
99116
99135
99140
Anesthesia for patient of extreme age, under 1 year and over 70
Anesthesia complicated by utilization of total body hypothermia
Anesthesia complicated by utilization of hypotension
Anesthesia complicated by emergency condition
1 (value units)
5 (value units)
5 (value units)
2 (value units)
Assignment of Benefits
Participating providers of service to Quad City Community Healthcare members and
dependents will be billed on the appropriate CMS approved forms or approved electronic
formats and will agree to accept assignment of benefits on the form or electronically. In the
event the appropriate indication is not made to accept assignment of benefits the provider
agrees by participating provider status to automatically accept assignment of benefits. For the
purposes of this section, “assignment of benefits”, accepting assignment is defined as the
provider will accept payment directly from QCCH or its payer partner and as per the
explanation of benefits the approved charge, determined by the provider agreement fee
schedule or exhibit as the full charge for the services covered under the members or
dependents benefit plan. The provider will not collect from the member or dependents or other
persons an amount that is not equal to the provider agreement fee schedule or exhibit and will
not collect from the member other than the applicable deductible, coinsurance or non-covered
services.
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Assistant Surgery
Quad City Community Healthcare claims processing of assistant surgery claims will follow the
payment policies and indicators as per the current year National Physician Fee Schedule
Relative Value File as published by CMS. For example, CPT’s with an indicator of 2 indicates
payment restrictions for assistant at surgery does not apply to this procedure and may be paid.
QCCH or its payer partner will reimburse the participating Physician according to his or her fee
schedule at 25% of the rate. QCCH or its payer partner will reimburse the participating
Physician Assistant or Nurse Practitioner according to his or her fee schedule at 10% of the
rate. QCCH does not reimburse Registered Nurse First Assist. The RVU table to determine
CPT’s that are eligible for assistant surgery reimbursement can be located at www.cms.gov.
Check Issues Resolution
On occasion, a check that has been issued to a provider for reimbursement is either lost or
misdirected. In the event that a check is not received by a provider we must wait 30 days from
the date of check issue in order to proceed with a check trace and re-issue.
Coordination of Benefits
Quad City Community Healthcare may, in some cases, be secondary payer to a primary
insurance plan or a government health plan such as but not limited to Medicare using "benefit
less benefit" methodology. In the event that QCCH is the secondary payer, QCCH will
consider the amount "after" the primary insurance has processed a claim with submission of
the primary insurance or government health plan explanation of benefit or remit accompanying
the appropriate CMS approved claim form. When considering allowable rates in coordination
with the primary insurance plan, QCCH will adjust allowable rates based on member
responsibility after the primary insurance has considered all charges. QCCH will not consider
an amount greater than what the contractual amount is would have been under the mutual
provider agreement and will not consider allowed amounts that would exceed the primary
insurance allowed amount.
If the primary insurance has an allowable that is higher than the allowable rate in which QCCH
would have allowed had it been the primary payer, QCCH will only consider the contract
allowable rate as if QCCH was the primary payer.
If the primary insurance has an allowable that is less than the allowable rate in which QCCH
would have allowed had it been the primary payer, QCCH will only consider the up to the
primary payer allowable.
When considering coordination of benefits, at no time will QCCH consider an allowable greater
than the patient responsibility after the primary insurance has processed a claim.
Contracted providers are required to submit claims in behalf of the member when QCCH is the
secondary payer the same as if QCCH had been the primary payer. In addition, contracted
providers are required to accept the additional discounts, if any, when QCCH is the secondary
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payer and refrain from billing these discounts to the member. When QCCH is secondary, the
agreement between the contracted provider and QCCH is still in force.
Laboratory Handling Fees
Laboratory handling fees, shipping fees and non-clinical services are not reimbursed under our
provider agreements. These services should not be billed to a member. In certain
circumstances, it may be medically necessary for a laboratory to provide a service at a
member’s home. These services will only be reimbursed when medical necessary. Pre
authorization is recommended.
Laboratory Professional Component
Providers contracted with Quad City Community Healthcare will not be reimbursed for a
professional component for laboratory codes with the exception of pathology and cytology.
Professional component of laboratory services is considered inclusive to the cpt code billed as
global. QCCH members are not responsible for the professional component of laboratory
services. Explanation of benefits and provider remittance will indicate a claims edit or not
covered, member not responsible for these charges.
Lesser Of Policy
Quad City Community Healthcare requires providers to bill their usual and customary fee
schedules for their practice or facility. This will assist in effectively pricing our fee schedules.
Please do not bill contractual rates.
Lesser of will apply. Reimbursement will be the lesser of the billed charge or the contracted
rate listed on the exhibit or fee schedule.
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Modifiers
Modifier
21
22
23
24
25
26
32
47
50
51
52
53
54
55
56
57
58
Prolonged Evaluation and
Management Services
Increased Procedural Services
Unusual Anesthesia
Unrelated E/M service by the same
physician during a postoperative
period.
Significant, separately identifiable
E/M service by the same physician
on the day of a procedure or other
service
Professional Component
Mandated Services
Anesthesia by Surgeon
Bilateral Procedure
Multiple Procedures
Reduced Services
Discontinued Procedure
Surgical procedure only
Postoperative management only
Preoperative management only
Decision for surgery
Staged or related procedure or
service by the same physician
during the postoperative period
Information
Required
1-Medical Records
2-Operative Report
3-Both 1 & 2
4-No Records
1-Medical Records
3-Both 1 & 2
4-No Records
1-Medical Records
4-None
4-None
4-None
4-None
4-None
4-None
1-Medical Records
3-Both 1 & 2
4-None
4-None
4-None
4-None
3-Both 1 and 2
Distinct procedural service
Two surgeons
Procedure performed on infants less
than 4 kg
Surgical Team
Repeat procedure or service by
same physician
Repeat procedure done by another
physician
Unplanned return to
operating/procedure room by same
physician following initial procedure
for related procedure during
postoperative period
4-None
2-Operative Report
3-Both 1 & 2
79
Unrelated procedure or service by
the same physician during the
postoperative period
3-Both
80
Assistant Surgeon
4-None
59
62
63
66
76
77
78
14
Description
2-Operative Report
3-Both 1 & 2
4-None
3-Both
Updated 07/01/2014
81
82
90
92
99
AA
AD
AS
TC
QK
QX
QY
Minimum assistant surgeon
Assistant surgeon when a qualified
resident is unavailable
Reference laboratory
Alternative laboratory platform
testing
Multiple modifiers
Anesthesia Services performed
personally by anesthesiologist
Medical supervision by physician
more than 4 concurrent anesthesia
procedures
PA, NP or clinical nurse specialist
services for assistant at surgery
Technical component
Medical direction of 2, 3, or 4
concurrent anesthesia procedures
involving qualified individuals
CRNA services with medical
direction by a physician
Medical direction of one CRNA by
anesthesiologist
4-None
4-None
4-None
4-None
4-None
Not allowed by QCCH
Not allowed by QCCH
4-None
4-None
Not Allowed
Not Allowed
Not Allowed
Not Allowed
QZ
Multiple Procedure Discount
Quad City Community Healthcare reimbursement of multiple procedures will follow the
payment policies and indicators as per the current year National Physician Fee Schedule
Relative Value File as published by CMS. For example, CPT’s with an indicator of 2 will
receive the “standard payment adjustment rule for multiple procedures”. The CPT’s will be
ranked according to weights. The highest weighted procedure will reimburse at 100% of the
agreed upon rate while all other CPT’s ranked at a less weights will take the 50% multiple
procedure discount. The RVU table can be located at www.cms.gov.
Prevailing Policy
For all participating providers with Quad City Community Healthcare, please refer to your
Provider Participating Agreement when determining a prevailing policy. Your participating
provider agreement will prevail over the QCCH Provider Manual in the event of a conflict or
dispute. For clarifications of any policy or provider agreement, please contact customer
service.
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Rate Calculations When Not On Schedule or Exhibits
Occasionally a procedure will fall to a non specific code within a category when it cannot be
otherwise categorized. When this occurs and a non specific code is billed it must be
accompanied by a clear description. These codes are not assigned weights therefore several
steps need to be taken in order to correctly reimburse the procedure.
1. The code billed to QCCH will be reviewed and compared to the description to determine if
another code would have been more appropriately used. In this instance, the claim will be
denied requesting the claim be refilled using a more appropriate code.
2. If it is determined there is not a more appropriate code, the claim will be directed to a
physician adviser to determine if there is a similar procedure that a weight can be established
and rates be calculated according to the fee schedule conversion factor.
3. If there is not a similar procedure to establish a weight, the code will be reimbursed at our
standard percentage or percentage of usual and customary until at such time a number of
claims are received with this description and an average price can be established. This
process would only be used until a new code with weights is assigned to the procedure
Codes that have not been weighted or are not priced on the fee schedule will be handled in the
same manor taking every step to ensure the appropriate reimbursement with the following
exception. If a code has been assigned a weight since the fee schedule was established the
code will be priced at the current published weights multiplied by the conversion factor
assigned to the range of codes applicable. If this information is not available then the steps
outlined above will be followed.
Occasionally, QCCH may request additional information such as medical records, further
procedure description or in the case of HCPC’s a package insert may be requested for drugs
or DME.
Drugs, immunizations, and biologicals that are not otherwise categorized or has not been
assigned an ASP rate, will reimburse at 87% of the current Red Book average wholesale price
or 87% of current average wholesale price as listed by the current pharmacy benefits
administrator until an ASP calculation is published by CMS.
Sales Tax
Sales tax is not a medically necessary service and not considered reimbursable to a provider.
Sales tax should be considered part of the service provided to a member and is included in the
contract allowable. These charges are not allowed to be passed on to the member.
Timely Filing
Filing of claims, corrections, claim inquiries and appeals must all be completed within 365 days
of the date of service. We request that initial claims filings be within 90 days of the date of
service in order for prompt reimbursement for the employer, employees and to our providers.
No claim will be considered or reconsidered after 365 days from the date of service.
Updated 07/01/2014
16
Provider Claim Inquiry and Appeals Process
Provider Claim Inquiry
Most claim inquiries can be handled by a telephone call to customer service at 563-322-8995
or 1-888-498-7224. Your customer service representative will assist you with your questions
of how claims were processed and initiate a Claim Inquiry. In the event a provider disputes a
claim, the provider has 365 days from the date of service to ask for the claim inquiry, submit a
corrected claim, submit additional information to aid in the processing of a claim, review of a
denied claim or under/overpayment of a claim.
A Claim Inquiry may be submitted by mail by using the Claim Inquiry Form and mailing to:
Quad City Community Healthcare
Attention: Provider Claim Inquiry
246 W 3rd Street Suite 100
Davenport IA 52801
*Please refrain from submitting Claim Inquiry and Forms to claims mailing addresses.
Claim Inquiry submitted by mail will need to include a completed Claim Inquiry Form, corrected
claim, medical records and documentation to support a corrected claim, medical records and
documentation that may need to be submitted for the review of the denied claim.
If your initial claim inquiry does not satisfactorily resolve the claim and you have additional
information, please submit a second inquiry with the new information available. Please advise
the customer service representative if this is a second inquiry or mark your Claim Inquiry Form
as a second inquiry.
Sample Claim Inquiry Form on next page. Call customer service for additional forms at 563322-8995 or 1-888-498-7224.
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Provider Appeal
If you have exhausted the claim inquiry process you may dispute a claim adjudication action by
submitting a provider appeal for post service claims only. A provider appeal must be submitted
within 180 days of the date on the remittance advice but before 365 days from the date of
service using the Provider Appeal Form. The form must be completed and must be
accompanied by any medical records and documentation to be considered with the appeal.
A Provider Appeal may be submitted by mail by using the Provider Appeal Form and mailing
to:
Quad City Community Healthcare
Attention: Provider Appeals
246 W 3rd Street Suite 100
Davenport IA 52801
The provider appeal process is not to be used in place of the member appeals process.
Members may appeal pre and post service claims under the member appeals process. A
member may appoint a provider as an authorized representative to submit a member appeal
on their behalf. The provider would then need to follow the member appeal process. Please
contact customer service at Quad City Community Healthcare at 563-322-8995 or 1-888-4987224 for the plan specific member appeal process.
Sample Provider Appeal Form on next page. Call customer service for additional forms at
563-322-8995 or 1-888-498-7224.
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Credentialing and Recredentialing
General Policy
All providers, practitioners, facilities and ancillary providers must be credentialed by the plan
prior to rendering services to member of the plan as per your provider agreement. Contracted
providers will be prohibited from balance billing members for services rendered prior to
credentialing approval. Providers may not bill incident to another practitioner in lieu of
credentialing. Recredentialing will take place approximately every 3 years.
The credentialing and recredentialing policy is designed to protect the membership of the
health plan as well as update records accordingly to maintain adequate provider network
access, demographics and provider directories.
All participating providers, practitioners, facilities and ancillary providers are required to inform
the plan of changes to demographics such as but not limited to practice location changes,
remit to information changes, W9 information, telephone and contact numbers. Please also
notify the plan when practitioners are no longer practicing under your tax id/group practice.
Professional Liability Malpractice Coverage
As per the contractual agreement with Quad City Community Healthcare, providers must
maintain professional liability malpractice coverage insurance at all times not less than
$1,000,000 per occurrence and $3,000,000 in aggregate annually.
If at anytime the policy terminates, is not renewed, or is reduced in coverage the provider must
notify Quad City Community Healthcare in writing within 10 days of the change.
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Medical Services
Case Management Program
The purpose of the Case Management Program is to identify potentially high risk, high cost
members and to develop and implement high quality, cost effective care plans. The primary
objective is to insure quality, cost effective care through the development of individualized care
plans that require effective communication and collaboration with the member, providers, case
manager and benefit managers.
Case Management
Quad City Community Healthcare is committed to working in partnership with the member,
physician, other providers (i.e. home health and infusion therapy providers), family, resources
in the community. QCCH RN Care Managers will coordinate high quality, appropriate care, in
the most appropriate setting, by the most appropriate provider, in the most cost effective
manner. Depending on the case, if necessary, the RN Care Manager will do a case review
onsite and/or attend patient staffing meetings to assist with discharge planning.
There are several key components of the Case Management program, including health
education, care plan coordination, including the use of community resources and discharge
planning.
Case identification can occur in several different ways, including, but not limited to: a) during
the inpatient UR process, i.e. repeated hospitalizations, chronic disease, compliance
monitoring needs, high cost/high risk members, b) high cost specialty services, i.e. transplants,
c) abuse/neglect issues, d) end of life care.
Utilization Management Program
Components of Utilization Review will include:
Concurrent Review
Concurrent Review will be performed by RN Care Managers (Nurse Reviewers) to assess the
appropriateness of admission and continued stay. This will be accomplished through
telephonic review utilizing industry standard criteria, in cooperation with the
participating/nonparticipating hospitals UR departments. Discharge Planning and Case
Management opportunities will be identified at this time. The frequency of review will be based
on the specific facts of the case, including diagnosis and the existence of any co-morbidities
that may adversely affect the outcome or length of stay. If necessary, the RN Care Manager
will do the review onsite. Any issues identified will be discussed with the attending physician
and concerns will be reviewed with the local Medical Director or Physician Advisor.
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Preauthorization
Preauthorization is a process for authorizing services on a pre-service basis for a defined list of
diagnostic/surgical procedures, durable medical equipment and pharmacy based on approval
criteria. Depending on the situation, it may also require additional medical director review as
well.
Referral Management
Quad City Community Healthcare will have an in network benefit and open access to all
participating providers and an out of network benefit, in the event that a member chooses to
seek care outside of the network. In the event that a service is not available in the network, a
preauthorized referral will be required to assure that the in network level of benefit is applied.
Quad City Community Healthcare RN Nurse Reviewers may authorize referrals for out-ofnetwork services based on a set of approved criteria/standing orders. When the RN Nurse
Reviewer cannot approve the referral, it must be referred to the Medical Director or Physician
Advisor for a medical decision to be made.
Decisions will be made in a timely manner. Once all information needed for the review is
obtained, a decision will be communicated back to the physician and the member within 24-48
hours during regular business days.
Timeliness of Review Decisions
Quad City Community Healthcare is committed to insuring that medical management decisions
are made in a timely manner.
Utilization Review decisions (approvals and denials) will be communicated to Participating
Providers with 24-48 hours during regular business days of receiving all of the pertinent clinical
information. Written confirmation of the decision will be sent to the member and provider
within 2 business days of the decision.
All Utilization Management will be performed by Quad City Community Healthcare Registered
Nurses. The address and phone number is as follows:
Quad City Community Healthcare
246 W. 3rd Street Suite 100
Davenport, Iowa 52801
Ph: 563-322-8995 or 1-888-498-7224
Secure Fax: 563-322-8995
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